Wrestling Registration Form

Empire Academy of Eastern Iowa Registration
Athlete Information
Athlete's Name

First NameLast Name
Birth Date

MonthDayYear
Grade
T-shirt size (size used for sponsor shirts and state qualifier shirts)
AAU #:
AAU#
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Parent/Guardian Information
Name

First NameLast Name
Cell Number

Area CodePhone Number
E-mail
Additional E-mail
example@example.com
Emergency Information
Emergency Contact's Name

First NameLast Name
Relationship
Phone Number

Area CodePhone Number
Alt. Phone Number

Area CodePhone Number
Does the athlete have any allergies, chronic illness, or medical conditions? If yes, please describe.
My wrestlers picture can be taken and used on social media pages.
Informed Consent and Acknowledgement

I hereby give my approval for my child’s participation in any and all activities prepared by Empire Academy of Eastern Iowa. In exchange for the acceptance of said child’s candidacy by Empire Academy of Eastern Iowa, I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless Empire Academy and all its respective coaches, clinicians, and representatives from any and all liability for injuries to said child arising out of traveling to, participating in, or returning from all club activities.In case of injury to said child, I hereby waive all claims against Empire Academy, including all coaches and affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event. There is a risk of being injured that is inherent in all sports activities, including wrestling.
Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Signature

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Empire Academy of Eastern Iowa Registration